Provider Demographics
NPI:1386617561
Name:MOORE, MERWIN B (MD)
Entity type:Individual
Prefix:
First Name:MERWIN
Middle Name:B
Last Name:MOORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:639 BROADMOOR CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653
Mailing Address - Country:US
Mailing Address - Phone:870-424-4710
Mailing Address - Fax:870-424-4780
Practice Address - Street 1:639 BROADMOOR CIRCLE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653
Practice Address - Country:US
Practice Address - Phone:870-424-4710
Practice Address - Fax:870-424-4780
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003027560207X00000X
ARE5667207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5H201OtherBCBS - ARKANSAS
AR154348001Medicaid
MO209057108Medicaid
MO916964180Medicare PIN
AR5H201OtherBCBS - ARKANSAS
AR5H201Medicare PIN